Sept / Oct 2022 msms.org THE OFFICIAL MAGAZINE OF THE MICHIGAN STATE MEDICAL SOCIETY » VOL. 121 / NO. 5
Sept / Oct 2022 | michigan MEDICINE® 3 THOMAS J. VEVERKA, MD, FACS SAGINAW COUNTY Dear friends and colleagues, As we move into the fall, we have no idea what the colder months will bring—will we have yet another COVID wave? Will we face a full resurgence of the flu? Could Monkeypox become a full-blown pandemic? In the medical field, we face uncertainties like this every day. We can’t know what health issues or patient challenges we’ll face. At MSMS, we don’t have the power to predict what patients will present with, or where public health will chart its next course. What we can help reduce uncertainty with is a new federal rule that affects your practice management. In recognition of the importance of keeping the patient-physician relationship at the center of healthcare, many of us have been sharing visit summaries and treatment notes with patients for years. After all, our profession is frequently rated as one of the most-trusted among the public and a large part of that is from consistently open communication. While we appreciate that many practices have already adopted broad use of electronic health records and various methods of conveying them to patients, we want to ensure you have the most up-to-date information on everything you’re required to provide under the federal rule on health information technology and electronic health records. The feature article in this edition of Michigan Medicine® focuses on how to adapt your practice to one of constant connectivity with patients. Can we use this rule not as a burden, but as an opportunity to empower patients to take better charge of their health? By having all the same information as their physician, that’s exactly what they’ll be equipped to do. As always, if you have questions, that’s what we’re here for. Wishing you a pleasant fall, Thomas J. Veverka, MD, FACS MSMS President president 's “At MSMS, we don’t have the power to predict what patients will present with, or where public health will chart its next course. What we can help reduce uncertainty with is a new federal rule that affects your practice management.”
FEATURES & CONTENTS September / October 2022 12 Patient Medical Record Transparency: Help or Hindrance to the Practice of Medicine? In this edition of Michigan Medicine® we focus on how to adapt your practice to one of constant connectivity with patients. (Story begins on page 12.)
19 MSMS Education: Live, Virtual and On-DemandWebinars MICHIGAN STATE MEDICAL SOCIETY 22 As Telemedicine Best Practices Emerge, Assess Your Practice DAVID L. FELDMAN, MD, MBA, FACS ALSO INSIDE 06 Current State of Michigan’s Abortion Laws DANIEL J. SCHULTE, JD 08 The Value of Using Total Compensation Statements JODI SCHAFER, SPHR, SHRM-SCP 10 New Influenza Vaccine Recommendations Ahead of the 2022–2023 Flu Season MICHELLE DOEBLER, MPH MICHIGAN MEDICINE® VOL. 121 / NO. 5 Chief Executive Officer JULIE L. NOVAK Managing Editor KEVIN McFATRIDGE KMcFatridge@msms.org Publication Design HIAKATO DRACONAS associationpublications.com Advertising GRANDT MANSFIELD grandt@llmpubs.com Publication Office Michigan Medicine® PO BOX 950 East Lansing, MI 48826 517-337-1351 www.msms.org All communications on articles, news, exchanges and advertising should be sent to above address, ATT: Kevin McFatridge. Postmaster: Address Changes Michigan Medicine® Kevin McFatridge PO BOX 950 East Lansing, MI 48826 Michigan Medicine®, the official magazine of the Michigan State Medical Society (MSMS), is dedicated to providing useful information to Michigan physicians about actions of the Michigan State Medical Society and contemporary issues, with special emphasis on socio-economics, legislation and news about medicine in Michigan. Neither the editor nor the state medical society will accept responsibility for statements made or opinions expressed by any contributor in any article or feature published in the pages of the journal. The views expressed are those of the writer and not necessarily official positions of the society. Michigan Medicine® reserves the right to accept or reject advertising copy. Products and services advertised in Michigan Medicine® are neither endorsed nor warranteed by MSMS, with the exception of a few. Michigan Medicine® (ISSN 0026-2293) is the official magazine of the Michigan State Medical Society, published under the direction of the Publications Committee. In 2022 it is published in January/February, March/April, May/ June, July/August, September/October and November/December. Periodical postage paid at East Lansing, Michigan and at additional mailing offices. Yearly subscription rate, $110. Single copies, $10. Printed in USA. ©2022 Michigan State Medical Society STAY INFORMED – STAY CONNECTED! 27 NEW & REINSTATED MEMBERS
6 michigan MEDICINE® | Sept / Oct 2022 Current State of Michigan’s Abortion Laws By Daniel J. Schulte, JD, MSMS Legal Counsel Q: Can you explain the current state of Michigan’s abortion laws? In addition to the overturning of Roe v. Wade, I have been reading about more than one Michigan case involving injunctions. Is abortion now legal in Michigan? ASK OUR LAWYER In Dobbs v. Jackson Women’s Health Organization, the United States Supreme Court overruled Roe v. Wade and held that there is no longer a federal constitutional right to an abortion. Abortion procedures are now regulated by state law. State legislatures are free to enact, repeal, or revise existing abortion laws or to enact new abortion laws. State abortion laws (including the Michigan laws described on the next page) that were unenforceable prior to the overturning of Roe are now enforceable (absent court orders preventing their enforcement).
Sept / Oct 2022 | michigan MEDICINE® 7 Michigan law (MCL 750.14) has criminalized abortion procedures generally since the 1800s. The only exception included is applicable when the abortion procedure is necessary to preserve the life of the mother. This law is no longer dormant. Abortion procedures in Michigan are illegal. A violation of MCL 750.14 is a felony, with a potential maximum sentence of four years. If the violation results in the death of the mother, the potential maximum sentence increases to 15 years. Litigation ongoing at the time this column was written prevents the enforcement of MCL 750.14 in 13 of the 83 Michigan counties (Emmet, Genesee, Grand Traverse, Ingham, Jackson, Kalamazoo, Kent, Macomb, Marquette, Oakland, Saginaw, Washtenaw, and Wayne). An injunction preventing the enforcement of MCL 750.14 was issued by the Michigan Court of Claims in Planned Parenthood of Michigan v. Atty. Gen. of the State of Michigan. That injunction is currently on appeal. On August 1, 2022, the Court of Appeals issued an order providing that this injunction does not apply to Michigan’s county prosecutors. On the same day, in Gretchen Whitmer v. Linderman, et.al., the Oakland County Circuit Court issued a temporary restraining order preventing enforcement of MCL 750.14 by the prosecutors in the 13 counties who have stated they will enforce MCL 750.14. Therefore, abortion procedures are illegal in Michigan, but until the Whitmer temporary restraining order is terminated or a county prosecutor not subject to it changes his/her position, MCL 750.14 is not being enforced and physicians performing abortion procedures who comply with Michigan’s other laws regulating abortion will not be prosecuted. The situation is turbulent. Developments in the current litigation in addition to the outcome of a pending ballot initiative, the discretion of county prosecutors and legislative action (Michigan or federal) may change the enforceability of MCL 750.14 and other Michigan laws at any time. Two other Michigan statutes criminalizing certain abortion procedures are not subject to any court order preventing their enforcement. MCL 750.15 criminalizes the advertising or selling of any “pill, powder, drugs or combination of drugs, designed expressly for the use” of procuring an abortion except when the substance is sold by a prescription written by a physician practicing in the city, village, or township in which the sale is made and the seller of the substance registers the name of the purchaser, the date of the sale, the kind and quantity of the substance sold, and the name of the physician prescribing the substance. A violation of MCL 750.15 is a misdemeanor with a potential maximum sentence of one year. MCL 750.90h criminalizes the performance of partial birth abortions except when performed to save the life of the mother. A violation of MCL 750.90h is a felony with a potential maximum sentence of two years or a fine of not more than $50,000.00, or both. In addition to the laws described above, there are several other Michigan laws regulating abortion procedures. These laws include notice, consent and reporting requirements, immunity when refusing to perform an abortion, etc. These laws all remain enforceable. DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL IS A MEMBER AND MANAGING PARTNER OF KERR RUSSELL. MCL 750.15 criminalizes the advertising or selling of any “pill, powder, drugs or combination of drugs, designed expressly for the use” of procuring an abortion except when the substance is sold by a prescription written by a physician practicing in the city, village, or township in which the sale is made and the seller of the substance registers the name of the purchaser, the date of the sale, the kind and quantity of the substance sold, and the name of the physician prescribing the substance.
8 michigan MEDICINE® | Sept / Oct 2022 The Value of Using Total Compensation Statements By Jodi Schafer, SPHR, SHRM-SCP | HRM Services | www.WorkWithHRM.com Q:We are struggling in this jobmarket to not only attract employees, but retain the ones we have. Part of our challenge is that job candidates and current employees are expecting amuch higher salary than what we can pay. We provide a rich benefits package, but candidates and current employees are only thinking about salary. What can we do to help them see the whole picture of what we are offering? ASK HUMAN RESOURCES Unfortunately, the value of these benefits is rarely communicated with employees, which is why employees don’t often consider them when making decisions about whether to stay or go. In a labor market this tight, failing to provide current and potential employees with the dollar value of their total compensation (direct + indirect pay) is a missed opportunity. Therefore, you might consider creating total compensation statements, also known as total rewards statements, for each employee and prospective position. It’s not uncommon for employees to think only about the direct compensation they receive in the form of W-2 wages when evaluating the competitiveness of their current pay. However, as you indicate, employers often enhance hourly/ salary rates with indirect compensation as well, like paid time off, uniform allowances, health and wellness benefits, etc.
Sept / Oct 2022 | michigan MEDICINE® 9 A total compensation statement outlines the specifics related to pay (direct compensation) and benefits (indirect compensation) and the cost for each. It shows the employee (and prospective employee) what the practice is investing in them. When done well, being transparent about total compensation can increase your employees’ understanding of the total benefits they are receiving, which goes a long way toward building trust with your employees. The employee can also use this information to better assess and compare their total compensation to other employers. The process for creating total compensation statements is fairly straight forward. Often practices use an Excel spreadsheet and detail the specifics related to wages, including base pay and bonuses, the employer-paid costs for health and welfare benefits such as health, dental, and vision plans, short- and long-term disability, flexible spending accounts, life insurance, and retirement. They also include the quantitative value of employer- paid training/CE, paid time off, as well as federal social security, taxes, Medicare, workers’ compensation, and unemployment insurance paid on the employee’s behalf. Each employee receives this customized, itemized listing of the total investment you have made in them. For an example of a total compensation statement, visit: https://www.shrm.org/resourcesand tools/tools-and-samples/hr-forms/ pages/total-compensation-and- benefits-statement.aspx. It is essential that these calculations are error free and calculated consistently across employees. Expect employees to compare their numbers and if they find a mistake, they will doubt the accuracy of the entire summary, which can erode trust and confidence in management. For this reason, it is also important to ensure that you have internal pay equity before implementing total compensation statements. Employees in like positions with like circumstances (e.g. experience, education, performance) should be paid in a like manner. If you have concerns that you may not have a pay structure in place that is consistently applied, you should assess and make changes, as As you weigh the pros and cons, consider steps you can take to increase confidence and transparency in your practice’s total rewards structure. Overall, employees appreciate transparency from their employers and if it is communicated well and the data is clear and easy-to-follow, employees may truly see the full picture of your investment in their success. necessary, so that your transparency in sharing employee pay information does not backfire with a lot of questions that you cannot answer. Additionally, you will want to spend some time thinking about the communication method you will use to distribute this information to your team. Will employees view this process as justifying why their pay is not increasing? This can be a typical response and you can proactively address this by: a. Clearly communicating the purpose for sharing the total compensation statements (e.g., to increase transparency, so that they have the full picture and understanding of their pay and benefits, etc.). b. Ensuring a strong and consistently applied performance evaluation process so that any differences in pay due to performance is documented and has been discussed with the employee. c. Ensuring internal pay equity. As you weigh the pros and cons, consider steps you can take to increase confidence and transparency in your practice’s total rewards structure. Overall, employees appreciate transparency from their employers and if it is communicated well and the data is clear and easy-to-follow, employees may truly see the full picture of your investment in their success. This process, in and of itself, may also contribute to a more positive work culture, which is also a great retention strategy.
10 michigan MEDICINE® | Sept / Oct 2022 MDHHS UPDATE New Influenza Vaccine Recommendations Ahead of the 2022–2023 Flu Season By Michelle Doebler, MPH, Influenza Coordinator, MDHHS Division of Immunization In previous years, the Advisory Committee on Immunization Practices (ACIP) recommended annual influenza vaccination for everyone aged 6 months or older with any age-appropriate influenza vaccination available. However, on Thursday June 30, 2022 the Centers for Disease Control and Prevention (CDC) Director Rochelle P. Walensky, MD, MPH adopted the ACIP’s updated recommendation to preferentially recommend the use of specific flu vaccines for adults aged 65 years and older.1
Sept / Oct 2022 | michigan MEDICINE® 11 During the June 2022 meeting, ACIP voted to preferentially recommend the use of one of the following, higher dose flu, recombinant, or adjuvanted flu vaccines over standard-dose unadjuvanted flu vaccines for people aged 65 years and older. The preference applies to Fluzone High-Dose Quadrivalent, Flublok Quadrivalent, and Fluad Quadrivalent flu vaccines. The recommendation was based on a review of the available studies that suggest adjuvanted, recombinant, or high-dose flu vaccines in this age group are more effective than standard dose unadjuvanted flu vaccines. Dr. Walensky’s adoption of the ACIP recommendations makes this official CDC policy, which will be further detailed in an upcoming Morbidity and Mortality Weekly Report in the coming weeks. Each influenza season varies in severity, however, people aged 65 years and older typically are at higher risk of severe flu disease and account for most influenza-associated hospitalizations and deaths each year.2 It is estimated that between 70 and 85 percent of seasonal flu-related deaths have occurred in people aged 65 years and older. Additionally, changes in the immune system with increased aged indicate that older adults do not have as strong an immune response to vaccinations as younger people which can result in reduced protection against influenza. Adjuvanted, recombinant, and high-dose flu vaccines are important in this older population to reduce the likelihood of severe outcomes and can be more effective at reducing hospitalization and death compared to standard-dose unadjuvanted flu vaccines. Recently data has also shown that racial and ethnic health disparities exist in populations that receive a high-dose flu vaccine compared with standard-dose flu vaccines.3 Increasing access to higher dose flu resulting from wider distribution and availability of these vaccines could help reduce these health disparities. In previous years, CDC has not recommended any one flu vaccine product over another for any age group and there is still no preferential recommendation for individuals younger than 65 years. Everyone aged 6 months through 64 years is still recommended to receive annual influenza vaccination with any age-appropriate flu vaccine available. Additionally, adults aged 65 years and older should try to get one of the three preferentially recommended vaccines, however, if one of these vaccines is not available at the time of administration, individuals in this age group should not miss their opportunity to get vaccinated and should receive a standard- dose flu vaccine instead. CDC and the Michigan Department of Health and Human Services offer a plethora of resources to educate patients on the importance of annual influenza vaccination. Find out more about these updated recommendations at www.cdc.gov/flu and find resources and more at www.michigan.gov/flu. RESOURCES 1. Centers for Disease Control and Prevention (CDC) (2022). CDC Director Adopts Preference for Specific Flu Vaccines for Seniors. Retrieved August 8, 2022, from www.cdc.gov/media/releases/2022/s0630-seniorsflu.html 2. Centers for Disease Control and Prevention (2022). Influenza Adults 65 and Over. Retrieved August 8, 2022, from https://www.cdc.gov/flu/highrisk/ 65over.htm 3. Mahmud, S. M., Xu, L., Hall, L. L., Puckrein, G., Thommes, E., Loiacono, M. M., & Chit, A. (2021). Effect of race and ethnicity on influenza vaccine uptake among older US medicare beneficiaries: A record-linkage cohort study. The Lancet Healthy Longevity, 2(3). Retrieved August 8, 2022, from https://doi.org/10.1016/ s2666-7568(20)30074-x Each influenza season varies in severity, however, people aged 65 years and older typically are at higher risk of severe flu disease and account for most influenzaassociated hospitalizations and deaths each year.2
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Sept / Oct 2022 | michigan MEDICINE® 13 Fans of the hit 1990s sitcom, Seinfeld, regularly say its brilliance and success came from its ability to point out the humor in the events of our everyday lives. In 1996, just after the Health Insurance Portability and Accountability Act (HIPAA) was enacted, character Elaine Benes takes a sneak peek at her medical chart while her doctor is out of the room to find that someone had written she was “difficult” after a previous a visit. Elaine confronts her physician, Doctor Stern, and pleads her case trying to explain why she wasn’t being difficult when she refused to wear a gown at the appointment four years previous. “I wore a tank top,” she says. “Specifically so I wouldn’t have to wear a gown. Cause, you know, they’re made of paper.” Her doctor smiles and nods. “Well, that was a long time ago. Why don’t I just erase it,” he says as he takes his pencil eraser to her chart. “But it was in pen,” Elaine says. “You fake erased.” Doctor Stern takes his pencil and writes in her chart, but doesn’t allow her to see it. She transfers physicians, and makes attempts to steal her chart at the new practice to see their comments about her. But she never succeeds in getting ahold of her patient notes. Elaine would have appreciated the Information Blocking Rule of the 21st Century Cures Act. Old practice, new caveats Providing patients access to visit summaries is nothing new. Engaging patients not just during their visit, but immediately following it, is more likely to improve health outcomes by encouraging them to take an active role in follow-up care and monitor any issues identified. In fact, according to one study, many patients immediately forgot about half of the information communicated during an appointment. Forty-nine percent of decisions and recommendations were recalled accurately without prompting; 36 percent recalled with a prompt; 15 percent were recalled erroneously or not at all.1 Recently, the final rule on Interoperability, Information Blocking, and ONC Health IT Certification (“Information Blocking Rule”), part of the 21st Century Cures Act, nationally mandates that patients be granted access to all of the information in their medical records, electronically and without charge or delay, and through patient portals or, to the extent possible, through thirdparty smartphone applications (apps). In particular, the requirement stating that patients must be able to access information in their electronic health records “without delay” has raised many questions pertaining to physician note taking and practice management. You may find yourself asking: Does a patient really get access to all of the information I record about them? How much extra time will this require of me? What if a patient takes issue with how I say something? What if they don’t understand a clinical summary or have questions about lab results, etc.? In fact, however, there are many valuable note taking strategies that support transparency, quality, and—most of all—improved patient outcomes. Transparency builds trust According to MSMS Legal Counsel, Kathleen Westphal of Kerr, Russell & Weber, the increased transparency afforded under the Information Blocking Rule aligns well with the Open Notes concept. “Initially, there were questions about logistics and concerns regarding how compliance with the Information Blocking rule will impact a physician’s practice,” says Westphal. “Over time, we’re seeing that with increased transparency with patient notes, there is more opportunity for improved communication regarding a patient’s treatment, better engagement by patients, and an overall strengthening of the physician-patient relationship. This generally leads to fewer complaints and better outcomes.” Some physicians worry that the direct tone of their notetaking, or recording sensitive subjects, such as patients not following care instructions, will offend. Others worry that the clinical nature of their notes will be inaccessible, misconstrued, or lead to further worries about Does allowing patients quick and easy access to the information in their medical record improve patient care? Yes— but simple adjustments can maximize the benefits of full information sharing. (CONTINUED ON PAGE 14)
14 michigan MEDICINE® | Sept / Oct 2022 a diagnosis. In fact, studies show that many patients feel better about their provider after reading their visit notes. Positive effects on the patient-provider relationship may be most significant among vulnerable patients, such as those with fewer years of formal education.2 In the same study, among doctors, 26 percent anticipated documentation errors and 44 percent thought patients would disagree with notes. After a year, however, 53 percent believed patient satisfaction increased, and 51 percent thought patients trusted them more. Many physicians are using the mandated release of patient data electronically as an opportunity to help patients assume greater involvement in their own health journeys—which is proving to result in better health outcomes. “Info blocking should not be viewed as ‘black or white’; it is okay to consider your patient’s needs while thinking about compliance. Physicians should strike a balance between strict regulatory compliance and exercising his/her independent professional judgment—guided by personal and professional beliefs—as to what is in the best interests of patients, the profession, and the community.” AMERICAN MEDICAL ASSOCIATION 3 According to the American Medical Association, patients who read their physician’s notes say they: • Feel more in control of—and engaged in—their health care • Recall their care plans more accurately • Are better prepared for visits • Have a better understanding of their medical conditions and medications • Are more likely to adhere to their treatment plans • Can identify clinically important errors in their notes • Are not more worried or offended after reading their notes • Have more successful conversations and stronger relationships with their doctors
Sept / Oct 2022 | michigan MEDICINE® 15 When composing notes, certain strategies raise the odds that notes will be well understood and well received. Beyond being clear and succinct, strategies for success include: 1. Invite patients to participate in the note-writing process: During the visit, ask patients to read their notes, and check for understanding and accuracy. Encourage patients to refer to notes. 2. Consider beginning your note with the Assessment and Plan section. Many EHR systems allow your locking style to change based on your needs, i.e., you document in a typical subjective, objective, assessment, and plan (SOAP) format, but once locked, the assessment and plan are front and center. Include only pertinent aspects of current visits, and avoid importing multiple pages of data available elsewhere in the EHR. 3. Consider composing at least a portion of the note as instructions addressed directly to the patient. More direct language may help reinforce instructions for patients. For example: “Start taking lisinopril and check your blood pressure twice a week,” vs. “Initiated lisinopril and instructed her to check her blood pressure twice a week.” 4. When possible, use boldface text or other visual emphasis to call out important items such as “check your blood sugar twice a day.” 5. Avoid jargon. Patients don’t expect layperson’s terminology, but they need to be able to follow the note. 6. Make technology work for you. Use electronic tools to convert abbreviations to full spelling. Create templated versions of explanations that you frequently provide. 7. If you must use some shortened terms, take care to avoid those that might be particularly offensive if misconstrued. For example, a physician might use the accepted abbreviation for “follow up regarding shortness of breath,” “which could easily be misunderstood by a patient. 8. Caution patients about the potential for misunderstandings, and/or include templated statements and offer a list of common medical abbreviations. Another solution is inserting links to reliable online resources for clarification regarding medical terms. 9. Directly and respectfully address concerns. For example, for patients with obesity, review body mass index to clarify that emotionally fraught terms like overweight, obese, and morbidly obese are clinical terms, and not subjective judgments imposed by the physician. 10. Use supportive, nonjudgmental language. For example: “Patient lost five pounds and is motivated to continue positive trend toward goal of 20 pounds” vs. “Patient still needs to lose another 15 pounds.”Another example would be: “Patient chose not to pursue treatment” vs. “Patient refused treatment.” 11. Avoid subjective comments regarding the patient’s appearance or manner. 12. Plan ahead for 2023: • Staff task notes will also become accessible to patients. Start training practice staff to keep any subjective comments out of written communication. • Interoperability requirements for EHRs will include mobile devices like cell phones or the Apple Watch. During the worst of the COVID pandemic, numerous public opinion surveys showed that doctors were the most trusted source of information, topping government agencies, politicians, and the news media.4 While there are always certain to be outliers, it’s evident that access to clear, concise information builds patient trust and understanding. The editing process: or lack thereof One of the biggest changes to the rules that govern dissemination of information to patients electronically is the immediacy required. The rule now in effect says that patients must be able to access information in their medical records “without delay.” While there is no requirement for adapting notes to the ‘open note’ style, many physicians are choosing to use less ‘medical speak,’ including fewer abbreviations and technical terms, so that patients are readily able to understand and digest the information provided to them. One of the hardest pieces of getting used to this open-format communication style is how to address sensitive topics, such as diagnoses of serious illness, weight management, and/or mental health concerns. Surprisingly, some patients have reported that they appreciated direct language used in their notes, and that it helped them take their health more seriously. Clinicians in one study found that when some patients read visit notes about obesity or substance abuse, they were more motivated to attempt difficult behavioral changes. Some patients reported that “seeing it in black and white” made it more real.5 The Doctor’s Company outlines 12 strategies for successful open note-taking 12 Strategies for a Smooth Transition to Open Notes (CONTINUED ON PAGE 16)
16 michigan MEDICINE® | Sept / Oct 2022 In most cases, a patient’s immediate access to their complete medical records including test results will lead to quality and satisfaction for all parties. A learning curve will be present for some patients, and it’s wise to share with them how to contact your office in the case they don’t understand something or believe an entry may be incorrect. “Some physicians have expressed concerns about a patient misunderstanding their notes or misinterpreting test results and the potential impact to the patient,” says Westphal. “In these circumstances, physicians should talk with their patients and let them know how they can ask questions or obtain clarification regarding their notes or test results, whether at the patient’s next visit, or for more urgent concerns, calling the office or using the practice’s patient portal.” Be familiar with what the patient has the right to ask, what you can grant and/or refuse, and how to amend information in their medical record, including: • Patients have the right to request amendments to their medical records: The Health Insurance Portability and Accountability Act (HIPAA) requires a signed, dated request from the patient regarding what they want changed and why. • Providers have the right to determine whether the requested amendment will be made: The provider must respond, in writing, within 60 days of receipt of the patient’s request. • Common reasons to deny a patient’s request include that the provider who received the request did not create the record entry, or that the medical record is accurate as is. • The patient’s request and the provider’s response both become part of the patient’s medical record.6 The OpenNotes organization has communication resources available for use instructing patients how to understand their medical records and ask for clarifications as needed, such as posters for patient waiting areas or exam rooms, and printed communications that can be mailed or provided at appointment check-ins.7 Interoperability and continuing requirements Legislators put these rules in place to increase collaboration between health care providers and their patients, allowing for better quality health care, but it could come at a cost to those who have outdated technology, according to the The Doctors Company: A stumbling block to reaching true interoperability is when electronic health record (EHR) vendors closely guard data, which harms the transparency and open communication aspect of getting information directly to patients. The ultimate goal of the Cures Act is to support patient care by addressing health information technology hurdles across the continuum of care, and information blocking is strongly discouraged. Additionally, open notes are becoming even more, well…open. Starting in 2023, patients will be able to see task notes from staff members in their record, which includes items like reminders from staff members to the provider to return a call from the patient. If they are not doing so already, staff members should begin composing task notes as if the patient can see them—because soon, that will be the reality. “It’s important that physicians implement and enforce information sharing policies and protocols that will work within their practice,” she says. “Physicians should also talk with their EHR vendors to confirm compliance and ways to provide more seamless access to patient notes.” “A stumbling block to reaching true interoperability is when electronic health record (EHR) vendors closely guard data, which harms the transparency and open communication aspect of getting information directly to patients. The ultimate goal of the Cures Act is to support patient care by addressing health information technology hurdles across the continuum of care, and information blocking is strongly discouraged.” THE DOCTORS COMPANY
Sept / Oct 2022 | michigan MEDICINE® 17 Recommended Resources More information on successfully complying with the Information Blocking Rule: • OpenNotes - https://www.opennotes.org/ • AMA Sharing Clinical Notes with Patients Toolkit - http://MSMS.org/AMASharingNotes • AMA Patient Access Playbook (pdf ) - http://MSMS.org/AMAPatientRecordsPlaybook • Information Blocking Resource Center - https://infoblockingcenter.org/ • AMA Information Blocking Part 1 - http://MSMS.org/AMAInfoBlocking • AMA Information Blocking Part 2 - http://MSMS.org/AMAInfoBlockingCompliance • MSMS Legal Alert: ONC Cures Act Information Blocking Final Rule - http://MSMS.org/ ONCCuresAct References 1. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0191940 2. https://qualitysafety.bmj.com/content/26/4/262 3. https://www.ama-assn.org/system/files/2020-11/info-blocking-compliance.pdf 4. https://chrt.org/wp-content/uploads/2020/07/CoverMichigan_COVIDInfo AndTrust_Final-.pdf 5. https://www.ama-assn.org/system/files/2021-04/sharing-clinical- notes-with-patients-toolkit.pdf 6. https://www.thedoctors.com/articles/open-notes-in-healthcare-the-good-thebad-and-the-ugly-of-the-cures-act/ 7. https://www.opennotes.org/communications/
Sept / Oct 2022 | michigan MEDICINE® 19 The MSMS Foundation has a library of on-demand webinars available, many of which are free, making it easy for physicians to participate at their convenience to meet their educational needs. MSMS EDUCATION: LIVE, VIRTUAL, ON-DEMAND WEBINARS
20 michigan MEDICINE® | Sept / Oct 2022 Once registered, you will receive an email within 15 minutes with links to watch the on-demand webinar and to complete the survey evaluation. Contact: Beth Elliott at 517/336-5789 or belliott@msms.org A Team Based Approach Training Modules Module 1: How to Develop a Pharmacist-Physician Collaboration Module 2: Medication Therapy Management Reimbursement and ROI Module 3: Best Practices for AddressingWorkflow, Resources, and Challenges Module 4: Patient Case Scenarios Other Webinars: Connecting Treatment Courts and Health Care Professionals CPT/ICD-10 Updates for 2022 Health Care Providers' Role in Screening and Counseling for Interpersonal and Domestic Violence: Dilemmas and Opportunities Improving Health Outcomes for Healthy Michigan Plan Patients: Using the Health Risk Assessment to Help Address Social Determinants of Health Integrating Pharmacists into Practice: The Missing Link for Comprehensive Medication Therapy Management Long COVID and Post-Viral Syndromes Update on Chronic Fatigue Syndrome, Part 1: Clinical Diagnostic Criteria for Chronic Fatigue Syndrome/CFS now called Myalgic Encephalomyelitis or ME/CFS Update on Chronic Fatigue Syndrome, Part 2: Uniting Compassion, Attention, and Innovation to treat ME/CFS Webinars that Meet Board of Medicine Requirements: A Day of Board of Medicine Renewal Requirements Human Trafficking Medical Ethics – Conscientious Objection Among Physicians Medical Ethics – Confidentiality: An Ethical Review Medical Ethics – Decision Making Capability Medical Ethics – Just Caring: Physicians and Non-Adherent Patients Medical Ethics – Reclaiming the Borders of Medicine: Futility, Non-Beneficial Treatment, and Physician Autonomy Medical Ethics – Research Ethics Pain and Symptom Management – Naloxone Prescribing Pain and Symptom Management – Balancing Pain Treatment and Legal Responsibilities Grand Rounds Series A Review of COVID-19 Variants Changes to Michigan’s Auto No-Fault Act for Physicians LGBTQ Health in MI: An Overview of Efforts to Improve Care & Reduce Health Disparities Navigating the No Surprises Act Update on the Omicron Variant Practice Management Series How to Protect Your Practice Navigating the State and Federal Surprise Billing Legislation: 2022 Update Office Billing Policies and Procedures for No Surprises Resources to Navigate Surprise Billing Requirements To register or to view full course details, please visit: msms.org/OnDemandWebinars
Sept / Oct 2022 | michigan MEDICINE® 21 A Day of Board of Medicine Renewal Requirements Date: September 23, 2022 Time: 8:30 am – 4:15 pm Location: In-Person, East Lansing Marriott Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org Annual Scientific Meeting Date: September 22, October 13, October 20-21, and November 17, 2022 Time: September / November 3:00 – 6:00 pm; October 8:30 am to 4:30 pm Location: September, October 13, and November: Virtual Conference; October: In-Person Conference, Westin Southfield Intended for: Physicians and all other health care professionals Contact: Brenda Marenich at 517/336-7580 or bmarenich@msms.org A Day of Board of Medicine Renewal Requirements Date: November 4, 2022 Time: 8:30 am – 4:15 pm Location: In-Person, Sheraton Ann Arbor Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org 26th Annual Conference on Bioethics — Contemporary Challenges in Clinical Bioethics Date: November 5, 2022 Time: 8:45 am – 4:00 pm Location: In-Person, Sheraton Ann Arbor Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org Grand Rounds Date(s): September 5, September 14, October 5, November 9, and December 14, 2022 Time: 12:00 – 12:45 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org Practice Management Date(s): September 14, October 5, and December 14, 2022 Time: 12:00 – 12:45 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org Monday Night Medicine — Implicit Bias Date(s): October 3 and November 7, 2022 Time: 6:30 – 8:00 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org Wednesday Night Medicine — Implicit Bias Date(s): September 28, October 26, and November 30, 2022 Time: 6:00 – 8:00 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Beth Elliott at 517/336-5789 or belliott@msms.org Implicit Bias Two-Part Series — Reducing Unconscious Bias — an Imperative (RUBI) Part 1: Recorded Webinar Part 2 - Virtual Date(s): September 21, October 12, November 16, and November 30, 2022 Time: 12:00 – 1:00 pm Location: Virtual Conference Intended for: Physicians and all other health care professionals Contact: Brenda Marenich at 517/336-7580 or bmarenich@msms.org 2022 LIVE VIRTUAL CONFERENCES For more information or to register, please visit: MSMS.org/EO Questions? Contact Beth Elliott: email belliott@msms.org or call 517/336-5789
22 michigan MEDICINE® | Sept / Oct 2022 As Telemedicine Best Practices Emerge, Assess Your Practice David L. Feldman, MD, MBA, FACS, Chief Medical Officer, The Doctors Company and TDC Group, and Senior Vice President, Healthcare Risk Advisors
Contributed by The Doctors Company thedoctors.com more smoothly into their workflows,1 this moment calls for us to reconsider how we are using telemedicine relative to care access, quality, safety, and the core principles of patient-centered care. Specialty Example: Obstetrics Obstetricians monitor risk indicators like blood pressure and blood glucose, which help them intervene early in cases of preeclampsia and/or gestational diabetes. With the increasing availability of at-home monitors for blood pressure and blood glucose, the option to collect at-home metrics (which, admittedly, some patients do more reliably than others) shows how remote care can sometimes be safer and/or more accessible care. Surprisingly, I’ve heard obstetricians say they value telemedicine most with their high-risk patients, simply because it facilitates more frequent conversations. This finding also turns up in other specialties. Specialty Example: Otolaryngology As in obstetrics, the physical exam needs of otolaryngology might seem impervious to many telemedicine advancements. Yet the author of a 2020 JAMA article argued to his Many specialties, facing the pandemic’s imperative to improvise, formed similar discussion groups, which are now disseminating their findings via peer- reviewed medical journals or formulating best practices with their medical professional societies. Fortunately, each specialty’s findings have connotations for patients in a variety of settings. With 2020’s spike in telemedicine visits followed by 2021’s continued record-breaking increases,1 we now know a surprising amount about how to safely provide telemedicine care. As practices and hospitals work to integrate their telemedicine platforms Early in the pandemic, I heard an obstetrician say that a medical setting was the last place many patients were willing to go. As a result, he was checking on prenatal patients using telemedicine. With questions about standard of care in mind, I gathered obstetric leaders into a meeting group where providers discussed ways to safely utilize phone and video modalities to continue prenatal care beyond the pandemic. Would this modality, necessary in a time of crisis, be continued in the “new normal”? Sept / Oct 2022 | michigan MEDICINE® 23 (CONTINUED ON PAGE 24)
24 michigan MEDICINE® | Sept / Oct 2022 colleagues, “We must rediscover the nuances of palpation and noninvasive inspection. Substantial portions of this examination can be completed without instrumentation or prior experience.” The person without prior experience is the patient: “The clinician can provide instructions to the patient for sequential elements of the examination and then verify correct performance of each maneuver.”2 This collaborative spirit (which the author frames in terms of what Eric Topol, MD, of Scripps, has called the “activated patient”) aligns with the core principles of patient-centered care: “Patients are partners with their health care providers.”3 This partnership— facilitated by the practitioner while considering the patient’s emotional, social, and financial perspectives—is more than a remote-care convenience: “The activated patient is empowered to participate in their care in a manner hitherto unappreciated, and in so doing, they may well enjoy greater engagement and satisfaction.”2 Specialty Example: Surgery Surgical specialties present an unexpected number of opportunities for remote care, from consultative conversations all the way through postoperative evaluations. For instance, many post-op evaluations can relocate to the telemedicine space, where questions like how the wound looks and drain output can be evaluated. Such uses of telemedicine, when appropriate, improve the patient experience, and sometimes patient safety. After all, post-op patients don’t want to leave home, and sometimes safety is an issue. I know I’m not the only one who has ever made a house call during icy weather. If we use good clinical judgment, we can offer a version of the post-op house call to some patients with arguably comparable or improved patient safety. Reducing Medical Malpractice Risks Some of the state-to-state restrictions lifted early in the pandemic have resumed, so check with the relevant state medical licensing boards. It remains important to know where your patients are: Practicing medicine without a license is still illegal, and your medical malpractice insurer cannot cover you if you were doing something criminal, even inadvertently. We still see few medical malpractice lawsuits related to telemedicine, but those we do see mostly connect to diagnostic errors.4 Of course, the physical exam still matters: Even with workarounds and patient-assisted maneuvers, sometimes we need to lay hands on the patient. Moreover, since diagnostic errors often derive from communication gaps, we must remain mindful of the ways in which telemedicine amplifies communication challenges.4 That said, some methods of mitigating diagnostic error risks are contained within our challenge to embed telemedicine within workflows. Systems that require the physician to fulfill the role of a tech support professional and/ or medical assistant increase cognitive load. Such distractions increase the chances that a significant symptom will be overlooked. Further, systems that make it difficult to track referrals or test results amplify diagnostic risks. Therefore, better integrating telemedicine appointments into workflow serves both provider sanity and patient safety by optimizing patient-provider communication. You can engage experts like my colleagues at Medical Advantage to help your practice with this process. Telemedicine for Patient-Centered Care A recent survey found that 62 percent of responding organizations are expanding their telehealth programs, versus being in maintenance mode.1 This is the perfect time to rethink both what we need to do in person and how frequently we need to do it (e.g., ultrasounds during pregnancy), while accounting for the increasing availability of at-home gadgets, such as otoscopes and ultrasound solutions. Gadgets are one of the many aspects of telemedicine that raise questions about patient access to care. Patient safety researchers extol the virtues of programs that reduce device costs for patients in need, and they also promote reimbursement for providers who offer the substantial technology education and orientation some patients need to function as activated patients within the telemedicine landscape.4 Integrating translation services into virtual visits will also have an impact. The access question is two-sided, because for every patient who could not access a telemedicine visit for lack
of bandwidth or because they live in crowded conditions without privacy, there is a patient who could access their visit only because remote care comes without the price tag of childcare, transportation, or a missed shift. Despite its difficulties, telemedicine is a net gain to our armamentarium for providing patient-centered care. Board of Directors Disclosures House of Delegates Resolution 25-13 states that “MSMS annually provide Michigan physicians with a list of all officers, officials, candidates and staff who receive money as salary or non-patient care compensation from Blue Cross Blue Shield of Michigan (BCBSM) or any other insurer, medical product company or its affiliates annually in Michigan Medicine.” Following are the disclosures of the MSMS Board of Directors, officers and staff. Paul D. Bozyk, MD – None T. Jann Caison-Sorey, MD, MSA, MBA – None Pino D. Colone, MD – None Donald P. Condit, MD, MBA – None Jayne E. Courts, MD – None Talat Danish, MD, MPH, FAAP – None Robert M. Doane, MD – None Kaitlyn Dobesh, MD, JD – None Robert F. Flora, MD, MBA – None Thomas M. George, MD – None Paul S. Harkaway, MD – Did not disclose by print deadline Bryan W. Huffman, MD – None Larry R. Junck, MD – Did not disclose by print deadline Anna Kang – None Mark C. Komorowski, MD – None Nita M. Kulkarni, MD – None P. Dileep Kumar, MD – None Eric L. Larson, MD – None Melanie S. Manary, MD – None Mark E. Meyer, MD – None Christopher J. Milback, MD, MBA – None Dennis M. Ramus, MD – Board of Directors, Blue Cross Blue Shield of Michigan Michael J. Redinger, MD – None Daniel M. Ryan, MD – None M. Salim U. Siddiqui, MD, PhD – None Herbert C. Smitherman, Jr., MD, MPH – None F. Remington Sprague, MD – Board of Directors, Blue Cross Blue Shield of Michigan Brian R. Stork, MD – None Bradley J. Uren, MD – None Thomas J. Veverka, MD – None David T. Walsworth, MD – None John A. Waters, MD – None Mildred J. Willy, MD – None Phillip G. Wise, MD – Did not disclose by print deadline For further assistance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email. Sept / Oct 2022 | michigan MEDICINE® 25 The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered. Reprinted with permission. ©2020 The Doctors Company (thedoctors.com). USPS 2022 Statement of Ownership REFERENCE 1. Teladoc Health. 2021 Telehealth benchmark survey results and report. Published 2022. https://www.teladochealth.com/ resources/white-paper/HHS/2021-telehealth-benchmark-survey-results/ 2. McCoul ED. Grasping what we cannot touch: examining the telemedicine patient. JAMA Otolaryngol Head Neck Surg. Published June 18, 2020. https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2767512 3. What is patient-centered care? NEJM Catalyst. Published January 1, 2017. https://catalyst.nejm.org/doi/full/10.1056/ CAT.17.0559 4. Khoong EC, Sharma AE, Gupta K, Adler-Milstein J, Sarkar U. The abrupt expansion of ambulatory telemedicine: implications for patient safety. J Gen Intern Med. Published January 19, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC8768444/
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